1. www.rxdentistry.net

2. Edentulism  Once the teeth are lost, a continuous resorptive process  Results  Diminished volume and strength of residual bone  Loss of facial vertical dimension  Impaired masticatory function  Difficulty choosing a balanced diet  Speech difficulty  Facial soft tissue changes  Pathologic fracture possibility www.rxdentistry.net

3. SITE DEVELOPMENT  Reconstruction of deficient alveolar ridges that lacks sufficient volume, contour, or height  Ultimate surgical goal  Restore function, form, and long-term stability  Surgical approach selection  Type, size, and shape of the defect  Surgical expertise or experience level of surgeon  Intended direction of the augmentation www.rxdentistry.net

4. SITE DEVELOPMENT  Hard tissue management  Ridge(socket) preservation  Ridge augmentation  Vertical ridge augmentation  Horizontal ridge augmentation  Soft tissue management www.rxdentistry.net

5. SITE DEVELOPMENT  Hard tissue management  Ridge(socket) preservation  Ridge augmentation  Vertical ridge augmentation  Horizontal ridge augmentation  Soft tissue management www.rxdentistry.net

6. Defect size  Small edentulous segments (such as single tooth)  Particulate autogenous bone with membrane  (Fugazzotto 1997)  Large ridge reconstructions  Controversial  (Lang et al 1994, Chiapasco et al 1999)  Autogenous block bone  Extra-oral  Intra-oral  Distraction (>5mm vertical deficiency) www.rxdentistry.net

7. TMI  Bosker Transmandibular Implant (TMI)  In the late 1970s  Without the need for autologous bone graft  Technique sensitive both surgeon & prosthodontist  Significant “reversible complication” rate  22.2% (Keller et al, Int JOMI 1986;1:101)  Infection, superstructure fx, mandible fx, fail to osseointegrate www.rxdentistry.net

8. Ridge augmentation methods  Bone grafting  Biomaterials  GBR  Alveolar distraction osteogenesis www.rxdentistry.net

9. Distraction Osteogenesis for vertical ridge augmentation  History  1992, McCarthy and coworker  1996, Block & colleager ; dog  1996, Chin & Toth ; DO & Implant  Advantage  No additional surgery involving a harvesting procedure  No limit to lengthening  Simultaneous lengthening of surround soft tissue  Dis-advantage  Long treatment period  Need for suitable distractor  Danger of infection  Ilizarov (1989)  Preservation of blood supply at the corticotomy site  Kojimoto & coworkers (1988)  Preservation of periosteum : distraction  Vestibular incision rather than crestal incision www.rxdentistry.net

10. Ridge augmentation methods  Bone grafting  Biomaterials  GBR (Guided Bone Regeneration)  Alveolar distraction osteogenesis www.rxdentistry.net

11. Titanium membrane only  Cornelini (2000)  Ti-memb only, 3mm vertical ridge augmentation www.rxdentistry.net

12. Simultaneous implant placement and vertical ridge augmentation with a titanium-reinforced membrane: A case report  Vertical ridge augmentation with titanium reinforced memb.  2 nd surgery : 12 months later  3mm hard tissue augmentation  2mm dense connective tissue covered the newly formed bone www.rxdentistry.net Cornelini R, Cangini F, Covani U, Andreana S (Int JOMI, 2000;15:883-888)

13. Ridge augmentation methods  Bone grafting  Biomaterials  GBR  Alveolar distraction osteogenesis www.rxdentistry.net

14. Autogenous bone graft  Gold standard for bone augmentation procedures  Block bone or particulate forms  Block bone - reduced osteogenic activity & slow revascularization than particulate bone marrow  Extra-oral or Intra-oral donor-site  Intraoral harvested intramembraneous bone graft may have minimal resorption, enhanced revascularization, and better incorporation at the donor site www.rxdentistry.net

15. Autogenous bone graft  Advantage  Osteogenic potential  Block grafts that maintain form and shape  Ability to correct any size or shape deformity  Elimination of the possibility for an immunogenic reaction  Disadvantage  2 nd surgical intervention  Morbidity associated with the donor site  Unpredictable bone resorption  Longer recovery period  Difficulty in managing soft tissue coverage  Increased treatment time  Increased risks www.rxdentistry.net

16. Autogenous block bone grafts  Width deficiency  Veneer or saddle graft  Most predictable and resistant to resorption  Vertical deficiency  Onlay or saddle graft  Difficult to gain and maintain, high resorption rate  Combined deficiency www.rxdentistry.net

17. Donor Sites of Autogenous Bone  Cortical Bone  Mandible, Cranium  Cancellous Bone  Mx. Tuberosity  Inner Cancellous part  Cortico-Cancellous Bone  Iliac bone www.rxdentistry.net

18. Intra-oral vs Extra-oral  Kusiak et al (1985)  Intramembranous bone grafts accelerate revascularization and healing as compared to endochondral bone grafts  Cortical membranous grafts revascularize more rapidly than endochondral bone graft with a thicker cancellous part  Zins & Whittacker (1983), Philips & Rhan (1990)  Membranous bone (such as mandible) undergoes less resorption than endochondral bone (such as iliac crest)  Intraoral harvested intramembraneous bone grafts  Minimal resorption  Enhanced revascularization  Better incorporation at the donor site www.rxdentistry.net

19. Iliac bone www.rxdentistry.net

20. Chin bone www.rxdentistry.net

21. Ramus bone www.rxdentistry.net

22. Ramus bone www.rxdentistry.net

23. Chin vs Ramus  Complication (chin vs ramus)  Less cosmetic concern  Less wound dehiscence  No gingival recession  Less sensory disturbance  Less discomfort complain  Trismus & edema (medication) www.rxdentistry.net

24. Chin vs Ramus www.rxdentistry.net ParameterSymphysisRamus Surgical accessGoodFair to good Cosmetic concernHighLow Graft shapeThick rectangularThinner rectangular veneer Graft Size>1cm 3 <1cm 3 Graft MorphologyCorticocancellousCortical Graft ResorptionMinimal Healed Bone QualityType 2>type 1Type1>Type2 Post-OP pain/edema ModerateMinimal to moderate TeethCommon(temporary)Uncommon Nerve damageCommon(temporary) Uncommon Incision dehiscenceOccasional(Vestibular)Uncommon

25. Maxilla vs Mandible  Maxilla  More vascularity  Mandible  Less vascularity  Cortical bone perforation with bur www.rxdentistry.net

26. Critical Success Factors  Stability of grafting materials  Condition of recipient sites  No infections  Resistance to resorptions  Soft tissue coverage www.rxdentistry.net

27. Stability of grafting materials  Bony irregularity contouring  Graft fixation  Block bone : at least 2 fixation screws for immobilization www.rxdentistry.net

28. Condition of recipient sites  Inlay graft (3~4 wall defect)  More favorable  Onlay graft (1~2 wall defect)  More prone to resorption www.rxdentistry.net

29. Infection  Disrupt the process and halts the growth of new bone  Rupture of the soft tissue closure  Block graft exposure  Exposure time (2002, proussaefs)  Late exposure : no clinical & histologic sign of pathosis or necrosis  Early exposure : partial or total necrosis  Fixation screw infection  Adjacent teeth(structure) pathologic conditions www.rxdentistry.net

30. Resistance to resorption  Immobilization  Satisfactory to restore mandibular volume  In function the grafted bone underwent rapid resorption  Onlay graft  Use membranous bone & graft stability (Philips & Rhan 1990)  Cortical bone  Use of membrane  Adequate implant placement timing www.rxdentistry.net

31. Soft tissue coverage  Crestal incision with releasing incisions  Lingual flap  Mesially at least 3 teeth include  Raise extending beyond mylohyoid muscle  Tension-free suture  Mattress suture : contact over 3mm  Soft tissue graft  Free graft : FGG, CT  Pedicle graft : palatal or labial www.rxdentistry.net

32. Controversy  1 stage surgery (bone graft & implant placement)  Single surgical intervention  Potentially reduced healing time  2 stage surgery  Prosthetically better implant placement  Superior esthetics www.rxdentistry.net

33. 1 stage surgery  1 stage surgery (bone graft & implantation)  Long-term implant survival rates : 25~100%  Implant position & angulation are critical factors  Implant survival alone does not predict successful restoration of occlusion  Verhoeven et al 1997  Carr & Laney 1987  Marx & Morales 1988 www.rxdentistry.net

34. Advantage of delayed implantation  Reducing the infection rate & graft failure rate  Proper angulation & more precise positioning  After 5 years of masticatory functional loading  Onlay grafting & simultaneous implantation in maxilla  Success rate : 51~83%  Secondary implantation  Schliephake et al (1997, JOMS)  20% higher success rate www.rxdentistry.net

36. Resorption rate  Proussaefs, Lozada et al (2002)  Block graft with Bio-oss : 16.34 %, 17.58 %  Cordaro et al (2002)  Block bone : Mn 41.5%, Mx 43.5% (mean 42%)  Wang and colleagues (1976) : onlay bone graft  During the first 3 years : 14%~100%  Bell et al (2002)  Iliac crest block bone : 33% www.rxdentistry.net

37. The use of ramus autogenous block grafts for vertical alveolar ridge augmentation and implant placement: A pilot study  Ramus block autograft for vertical alveolar ridge augmentation  Ramus block bone, Fixation screws, Periphery : Bio-Oss  4~8 months later : HA implant (Steri-Oss)  Results  Radiographic  6.12 mm (1 month)  5.12 mm (4~6 months) : 16.34 %  Laboratory volumetric  0.91 mL (1 month)  0.75 mL (6 months) : 17.58 %  Peripheral pariculate bone (Bio-Oss)  Bone (34.33%), fibrous tissue (42.17%), residual Bio-Oss particle (23.50%)  Discussion  Early exposure appeared to compromised the results, while late exposure did not affect the vitality of the block autografts www.rxdentistry.net Proussaefs P, Lozada J, Kleinman A, Rohrer M (Int JOMI 2002;17:238-248)

38. Clinical results of alveolar ridge augmentation with mandibular block bone grafts in partially edentulous patients prior to implant placement  15 partially edentuous patients  Ramus & symphysis block bone  Fixed with titanium screw  After 6 months screw remove, implant placed  12 months later implant supported fixed bridges  Mean reduction rate  Lateral : 23.5%  Vertical : 42 %  Mandibular site more resorption rate than maxillary sites www.rxdentistry.net Groups No. of aug. sites Lateral aug. at bone grafting Lateral aug. at implant placement % reduction of lateral aug. Vertical aug. at bone grafting Vertical aug. at implant placement % reduction of vertical aug. Group 1 & 2186.5+0.335.0+0.2323.5%3.4+0.662.2+0.6642% Group 1 : Mx 106.5+0.65.2+0.420%4.75+1.52.75+1.541.5% Group 2 : Mn 86.5+0.374.75+0.1227.5%2.4+0.21.4+0.243.5% Cordaro L, Amade DS, Cordaro M (Clin oral impl res, 2002;13:103-111)

39. Staged reconstruction of the severely atrophic mandible with autogenous bone graft and endosteal implants  Materials and Methods  Vertical mandibular height <7mm (atrophic mandible)  Iliac crest bone graft to the mandible via an extraoral approach  After 4~6 months, implantation  Results  Mean pre-op bone height : 9mm (midline), 5mm (body)  Before implantation (4~6months) vertical bone loss : 33%  After implantation (24 months)  Non-implant supported region bone loss 11% per year  Implant-supported region bone loss negligible  Conclusions (improve success rates)  Prosthetically sound implant positioning  Provide an affordable reconstructive option  Staged reconstruction www.rxdentistry.net Bell RB, Blakey GH, White RP, Hillebrand DG, Molina A (JOMS, 2002;60:1135-1141)

40. Complications of grafting in the atrophic edentulous or partially edentulous jaw  Intraoperative complications  Bone  Insufficent donor material  Over-reduction  Inadequate fixation  Soft tissue  Perforation  Inability to mobile  Teeth  Root damage  Other anatomy  Sinus : membrane tear  Nerve injury  Postoperative complications  Gerneral  Infection  Bone  Excessive resorption (early exposure, loss of graft)  Inadequate bone for implant  Soft tissue  Hematoma  Flap retraction  Flap necrosis  Color or tissue-type mismatch  Loss of papilla  Shallowing of vestibule  Teeth  External root resorption  Other anatomy  Sinusities  Nasal bleeding  Oroantral fistula www.rxdentistry.net Bahat O, Fontanesi RVInt JPRD 21:487-495 2001

41. www.rxdentistry.net

42. Conclusions  Autogenous block bone graft (chin or ramus)  5~7mm gaining  About 30% resorption rate  Staging the grafting and implant procedure www.rxdentistry.net

43.  Primary stability (+)  Exposed threads can be covered with autogenous bone associated with a membrane  Jovanovic et al (1992), Jovanovic & Buser (1994), Giovannolli & Renouard (1995), Antoun et al (1996)  Primary stability (-)  Ridge augmentation should be performed before implantation www.rxdentistry.net